Dr. Eric Ball, a pediatrician in Orange County, is still guilty about the 2014 Disneyland measles outbreak.
At the time, his office allowed parents to refuse to vaccinate their children from still remaining as patients. Many people use this policy and have gone far below the 95% threshold that the experts say is necessary to achieve herd immunity during his practice. Ultimately, a single measles case at the theme park spread to 145 people nationwide. Some were part of his practice.
“I’ve been traumatized,” Ball said. “We felt like we weren’t doing enough as practice, and as pediatricians we didn’t do enough to persuade our families to get vaccinated.” Not only did the children of his anti-vaccine parents remained vulnerable to measles, but we were exposing other children in his waiting room where they were unable to receive the vaccine because they were too young or immunocompromised.
9 months old Noah watches Dr. Eric Ball, a Southern Orange County Pediatric Matchmaker at Ladera Ranch in 2024.
(Christina House/Los Angeles Times)
As a doctor, I felt the ball had torn apart. He had a moral obligation to care for all patients regardless of the vaccine choice of his parents. However, he was also obliged to protect other patients and other patients in the community from a deadly virus that is almost completely preventable.
Another outbreak of measles continues to spread in Texas and New Mexico, leading to the deaths of the first two US measles in a decade – and this year already in California, doctors are once again facing moral difficulties.
As we dig into parenting, interim kindergarten, health, and other issues affecting children ages 5 to 5, we will be involved in journalism funded by our community.
After the Disneyland outbreak, ball practice doctors decided to crack down on it. In 2015, they enacted a new policy. Pediatrics in South Orange County are no longer accepting patients who are planning to exempt children. Existing patients who do not want to be vaccinated should find a new doctor.
An increasing trend of rejecting unvaccinated patients
The “dismissal” policy was once discouraged by healthcare providers because pediatricians are obligated to care for all young patients, and because they are convinced that some anti-vaccine parents will change their minds over time.
However, in 2016, the American Academy of Pediatrics came up with new guidance. Vaccines against preventable diseases like measles were so important that after repeated attempts, if the pediatrician couldn’t convince the child to vaccinate the child, practice could properly kick them out.
“I think it made a huge difference for a lot of us. It gave us the cover,” Ball said.
Since then, layoff policies have become much more popular.
A study published in Journal Pediatrics found that in 2013, about 21% of pediatricians reported that they frequently or constantly rejected families who refused to vaccinate. By 2019, the stock had risen to 37%. Journal of the American Medical Assn. In a 2019 survey published in , more than half of pediatricians said their office had a layoff policy in place.
Dismissals are less common for families seeking to spread the vaccine on a different schedule. Only 8% of individual pediatricians reported that they frequently or constantly rejected these families, while 28% reported that their offices had such a dismissal policy, according to the academy.
Dismissal policies are far more common among private practices. Large health systems, including academic health institutions including UCLA, Kaiser Permanente, rural clinics, and safety net systems for low-income patients, generally accept all patients, whether parents plan to vaccinate their children or not. The Cedars-Sinai Medical Center is the exception, preventing clinic pediatricians from treating unvaccinated patients.
The question of whether to dismiss it is increasingly pressing amid increasing anti-vaccine sentiment and declining compensation. The proportion of kindergarteners across the country who completed the measles, mumps, and rubella vaccine series fell from about 95% (federal compensation targets) before the pandemic, before falling below 93% last year.
In California, 96.2% of kindergarteners were fully vaccinated against measles between 2023 and 24, a slight decrease from the previous year.
“No matter your policy, you feel ethically justified,” said Dr. Sean O’Leary, a professor of pediatrics at the University of Colorado Anschutz University Medical Campus, who co-authored the latest guidance on the latest vaccines from the American Academy of Pediatrics. In January, the New England Journal of Medicine presented the argument on both sides of the debate, with Allley writing a statement in favor of accepting unvaccinated patients. “I personally understand both.”
Why Doctors Dismiss Vaccinated Families
These days, many pediatric practices have existed in advance about their policies, and some can announce it on their website to let them know that future patients are away if they don’t want to get vaccinated.
For example, at Larchmont Pediatrics, Dr. Neville Anderson requires all patients to be vaccinated. If parents refuse to vaccinate the infant after a final conversation on a three-month visit, practice will send them an official termination letter.
Dr. Neville Anderson was photographed while receiving the vaccine at Larchmont Pediatrics in Los Angeles on Tuesday.
(Allen J. Scheven/Los Angeles Times)
“If parents are really anti-Vax and don’t want their children to be vaccinated, our values, our goals, and our beliefs are against each other and we are not a good team,” Anderson said. “I’m not the right doctor for them, they’re not the right patients for me,” she said, Larchmont only rejects one to four patients each year.
But for some patients, the dismissal policy is a real draw. “We have this policy so there are a lot of people who come to us,” Anderson said. “They are afraid to bring seven months into the waiting room where children are not vaccinated.”
Doctors should make every effort to convince the vaccine before families dismiss it, Dr. Jesse Hackel, a retired pediatrician in New York, said he co-authored the Pediatric Academy’s report on improving vaccine communications. The problem is that these conversations are time-consuming and unpaid for busy pediatricians whose patients only last 20 minutes. “It’s frustrating and one of the issues that lead to moral injuries and burnout.”
Hackel, 74, remembers the time before the vaccination. I remember many of his younger patients being hospitalized with measles and other vaccine-preventable diseases. “I don’t want to go back to the day when I’m worried about a 2am call about a child with a 105-degree fever. That’s not good for me as a doctor. It’s not good for children and families.” His practice had a layoff policy long before the Academy of Pediatrics said it was acceptable.
Doug Opel, a bioethicist and professor of pediatrics at the University of Washington School of Medicine, said one ethical argument in favour of the rejection is based on the moral obligation to vaccinate children to reduce the risk of infection with others.
Another point is, “vaccinations are considered a social contract,” he said. “So it’s not fair to share the collective benefits of vaccinating children without accepting the small burden of vaccinating them.”
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1. Dr. Neville Anderson tries to cheer up 4-year-old Iris Behnham, on the right, nurse Breana Kirby gives her DTAP polio and MMR Chickenpox (water cithina) vaccinations, while her mother, Haley Behnham, embraces her. 2. Dr. Neville Anderson tries to distract Perry Logi, right. 3. Dr. Neville Anderson was held by his mother, Christa Iacono, while he was receiving the flu, Covid and hepatitis B vaccinations at Larchmont’s pediatrics, along with seven-month-old Arlo Vasquez. (Allen J. Scheven/Los Angeles Times)
A moral case for accepting a family with vaccine syndrome
Opel, as a bioethicist, said he would come down to keep his family in practice.
“In other drug areas, do you expect patients and parents to have the same values and beliefs as us?” he asked. “Instead, we respectfully explore these values as a way to approach the difference between humility and find common ground and shared understanding,” Opel said about 30% of parents will change their minds. “Vaccination hesitation is a modifiable action.”
O’Leary said there is little evidence that accepting unvaccinated children could lead to the transmission of vaccine-preventable diseases in an office setting. And it is not clear whether the threat of termination actually persuades parents to get vaccinated, or whether patients who are kicked out of practice will find other sources of care.
LN San Diego County, Primary Care Healthcare Group for Children (a large practice with 28 offices in the area) has a policy to accept all patients regardless of their vaccination status.
“The basic philosophy is not the children who reject it, but the parents. And we don’t punish children for their decisions,” said Dr. Adam Breslow, president and CEO of the group.
Approximately 90% of the patients in the group are vaccinated as planned, Breslow said. Of the 2-3% who refuse all vaccinations, most come from wealthy areas where parents can afford to homeschool or send their children to private schools. He said he rarely persuaded him to get the vaccine on a single office visit, but for several years in his practice, some parents eventually change their minds.
“By keeping them in practice, they could be vaccinated,” O’Leary said. “But if you kick them out, who knows what will happen?”
Where do parents who don’t vaccinate their children go?
A widespread dismissal policy can make it difficult for families with vaccinations to find regular care sources. In local Facebook groups, parents often exchange tips about vaccine spread and refusal.
We recommend using Concierge practices. This charges thousands of dollars in annual fees in addition to insurance payments, but vaccination schedules may allow for flexibility. Some of these practices offer unproven alternatives to vaccinations with little or no evidence to back them up.
Escondido’s mother, Whitney Jax, recently posted to a group of moms on Facebook to help find new pediatricians who prefer to limit vaccines. Along with her older child, 7 years old, she was paying for a Maryland concierge doctor she saw on Zoom. However, her son does not have a regular pediatrician, so he meets experts several times a year, but skips his annual well visit.
Now pregnant with her second child, she was hoping to find a local to accept insurance and support her decision to wait until the baby starts vaccination until the baby is two years old.
Other mothers on the Facebook group were hesitant to share their names publicly, she said, for fear that doctors would get into trouble. One mom sent her a list of names. She set it up a meeting and gift appointment with the four people closest to her home.
But when she began to meet them, she gave her the same responses one after another. “We won’t kick you out, but we don’t like this,” said Jacks of Acupuncture Cup. “So they’ve already put you in disapproving your perspective.” She didn’t feel welcome.
She chose the most convenient office. However, Jacks worries that every visit will focus on vaccination instead of other issues such as feeding and sleep that have been important in the first few years.
“It doesn’t give me confidence or faith in my provider.”
This article is part of the Times Early Childhood Education Initiative and focuses on learning and development for California children from birth to age 5. To learn more about the initiative and its charity funders, visit latimes.com/earlyed.
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